Factors prognostic for survival in patients with malignant melanoma spread to the regional lymph nodes

Revealing the concealed: A tribute to Donald L. Morton, MD

Donald L. Morton, MD, epitomized one of America's dream scenarios: a person evolving from the humblest of origins to become an international celebrity in his profession, leading the world in the discipline of surgical oncology. His pioneering accomplishments in various roles have been well documented. Scientists, clinicians, students, and patients benefited from his contributions to the management of malignant diseases, particularly melanoma. His many attributes in pursuing the goal to cure malignant diseases are well known. Browsing the scientific literature reveals an almost unmatched publication record and continuous National Institutes of Health funding. He revealed dozens of original concealed ideas, not least of which is the tumor-draining regional lymph node, now called the sentinel lymph node (SLN). When others gave up on the original promise of immunotherapy, he saw the future, the clinical promise which has lately materialized in the control of previously untreatable malignancies. He regarded the fellowship-training of more than 100 surgical oncologists as one of his biggest achievements. In this article, we celebrate the human side of a man with creative courage and far-reaching insight.

Contemporary update of SPECT tracers and novelties in radioguided surgery: a perspective based on urology

Recent technical advances and implementation of novel radiotracers have further increased the potential of radioguided surgery for a broad variety of malignancies. Indeed, the possibilities for future applications of novel radiotracers in diverse oncological strategies has become more promising than ever. This literature review aims to provide a contemporary update on a selected group of radiotracers and evaluates the usability of radioguided surgery and sentinel node procedures, focusing on most promising advances. For example, the impact of targeted radiotracers on prostate specific membrane antigen (PSMA), CD206 receptor-targeted agents (^99mTc-tilmanocept), and hybrid tracers adding fluorescence to radioguidance (ICG-^99mTc-nanocolloid) as well as targeting hypoxia-induced carbonic anhydrase IX (CAIX) will be covered. Furthermore, future outlooks on the implementation of gold nanoparticles (AuNP's), but also technical advances in improved radiotracer detection by hybrid gamma devices will be discussed.

The prognostic impact of the extent of ulceration in patients with clinical stage I-II melanoma: a multicentre study of the Italian Melanoma Intergroup (IMI)

BACKGROUND

The presence of ulceration has been recognized as an adverse prognostic factor in primary cutaneous melanoma (PCM).

OBJECTIVES

To investigate whether the extent of ulceration (EoU) predicts relapse-free survival (RFS) and overall survival (OS) in PCM.

MATERIALS AND METHODS

We retrieved data for 477 patients with ulcerated PCM from databases of the Italian Melanoma Intergroup. Univariate and multivariable Cox proportional hazard models were used to assess the independent prognostic impact of EoU.

RESULTS

A significant interaction emerged between Breslow thickness (BT) and EoU, considering both RFS (P < 0·0001) and OS (P = 0·0006). At multivariable analysis, a significant negative impact of EoU on RFS [hazard ratio (HR) (1-mm increase) 1·26, 95% confidence interval (CI) 1·08-1·48, P = 0·0047] and OS [HR (1-mm increase) 1·25, 95% CI 1·05-1·48, P = 0·0120] was found in patients with BT ≤ 2 mm, after adjusting for BT, age, tumour-infiltrating lymphocytes, sentinel lymph node status and mitotic rate. No impact of EoU was found in patients with 2·01-4 mm and > 4 mm BT.

CONCLUSIONS

This study demonstrates that EoU has an independent prognostic impact in PCM and should be recorded as a required element in pathology reports.

Clinical impact of ulceration width, lymphovascular invasion, microscopic satellitosis, perineural invasion, and mitotic rate in patients undergoing sentinel lymph node biopsy for cutaneous melanoma: a retrospective observational study at a comprehensive cancer center

The prognostic significance of the width of the ulceration in primary melanomas remains unclear, and there is a relative paucity of data for lymphovascular invasion (LVI), microscopic satellitosis (MS), perineural invasion (PNI), and mitotic rate when compared with other pathological elements currently required for reporting. To evaluate the prognostic importance of the ulceration width and other important pathologic measurements, a single-institutional retrospective study was conducted using records of cutaneous melanoma patients who underwent sentinel lymph node (SLN) biopsy at The University of Texas, MD Anderson Cancer Center between 2003 and 2008. We identified 1898 eligible patients with median tumor thickness of 1.25 mm and median follow-up of 6.7 years. By multivariable analyses, the strongest risk factor for SLN positivity was high tumor thickness followed by the presence of LVI. The pathologic measures with the strongest influence on recurrence-free survival (RFS) were tumor thickness and positive SLN status. Ulceration width and presence of MS were also significantly associated with RFS while PNI was not. Factors with the strongest influence on melanoma-specific survival (MSS) were positive SLN status and mitotic rate. In conclusion, SLN biopsy should probably be offered if the primary tumor has LVI. MS is an adverse prognostic factor for RFS, but its influence on outcome is modest. Ulceration width predicts RFS but loses its independent prognostic significance for MSS when adjusting for currently used clinicopathological factors. In view of its impact on MSS, mitotic rate should be recorded for cutaneous invasive melanomas across all T categories.

Treatment Outcome and Prognostic Factors for Malignant Skin Melanoma Treated with Radical Surgery

AIM

To assess the treatment outcome in patients with malignant skin melanoma and prognostic factors for distant metastases (DM), disease-free survival (DFS) and overall survival (OS).

MATERIALS AND METHODS

A retrospective analysis was conducted on 113 patients with malignant skin melanoma (60 females, 53 males, average age-55 years) who were treated surgically. Primary treatment consisted of local excision. In 12 cases, it was accompanied by lymph node excision. In 93 (82%) cases, radicalization was necessary, which was either local only (19 cases) or accompanied by lymph node surgery/biopsy (74 cases). Possible prognostic factors such as Clark's stage and Breslow's depth of invasion, ulceration, average tumor dimensions, lymph nodes metastases (pN+), gender, tumor location and primary excision margins were considered.

RESULTS

In 51 (45%) cases, treatment failure occurred. The 5-year DM rate was 47%, the 5-year DFS was 38%, and the 5-year OS was 56%. In the univariate analysis, the important factors with respect to at least one endpoint included Clark's stage, Breslow's depth of invasion, ulceration, average tumor dimensions, lymph nodes metastases, gender and primary tumor localization. The presence of metastasic nodes was the most important prognostic factor, with a 5-year DM rates of 30% for pN(-) and 76% for pN(+) and a 5-year DFS and OS of 56% and 76% for pN(-) and 13% and 24% for pN(+), respectively. The average tumor dimension was independently significant for DFS and OS, with 5-year rates of 69% and 80% for ≤1 cm, 28% and 53% for 1-2 cm, and 18% and 30% for >2 cm, respectively. Tumor location was also significant for DM and OS, with 5-year rates of 69% vs 33% and 41% vs 66% for trunk vs other locations, respectively.

CONCLUSIONS

The natural course of a malignant skin melanoma treated radically is disadvantageous, with unsuccessful outcome in nearly half of the cases. Common clinical factors, such as Clark's tumor stage, Breslow's depth of invasion and the presence of metastatic nodes, have high prognostic significance. The size and location of the primary lesion may be considered independent prognostic factors. The most important negative prognostic factor is the presence of metastatic regional lymph nodes. Only one quarter of patients with metastases in lymph nodes survive 5 years from primary surgery.

[Update on surgical treatment of primary and metastatic cutaneous melanoma]

Melanoma is a common cutaneous tumour. It is of great importance due to its increasing incidence and aggressive behaviour, with metastasis to lymph nodes and internal organs. When suspecting melanoma, excisional biopsy should be performed to obtain complete histological information in order to determine the adverse factors such as ulceration, mitosis rate, and Breslow depth, which influence preoperative staging and provide data for sentinel lymph biopsy decision making. The indicated management for melanoma is wide local excision, observing recommended and well-established excision margins, depending on Breslow depth and anatomical location of the tumour. Therapeutic lymphadenectomy is recommended for patients with clinically or radiologically positive lymph nodes. This article reviews surgical treatment of melanoma, adverse histological factors, sentinel lymph node biopsy, and radical lymphadenectomy. Details are presented on special situations in which management of melanoma is different due to the anatomical location (plantar, subungual, lentigo maligna), or pregnancy.

Vascular cell adhesion molecule-1 (VCAM-1)--an increasing insight into its role in tumorigenicity and metastasis

Vascular cell adhesion molecule-1 (VCAM-1) first attracted attention more than two decades ago as endothelial adhesion receptor with key function for leukocyte recruitment in term of cellular immune response. The early finding of VCAM-1 binding to melanoma cells, and thus a suggested mechanistic contribution to metastatic spread, was the first and for a long time the only link of VCAM-1 to cancer sciences. In the last few years, hallmarked by a growing insight into the molecular understanding of tumorigenicity and metastasis, an impressive variety of VCAM-1 functionalities in cancer have been elucidated. The present review aims to provide a current overview of VCAM-1 relevance for tumor growth, metastasis, angiogenesis, and related processes. By illustrating the intriguing role of VCAM-1 in cancer disease, VCAM-1 is suggested as a new and up to now underestimated target in cancer treatment and in clinical diagnosis of malignancies.

[The importance of fine needle aspiration cytology in the management of recurrent and metastatic melanoma]

Fine needle aspiration cytology is a widely accepted, reliable diagnostic modality for the early detection of metastases.

OBJECTIVE

Quality assurance analysis of fine needle aspiration cytology in melanoma patients.

METHOD

A total of 194 biopsies performed in 142 melanoma patients were analyzed retrospectively.

RESULTS

138 (71.13%) cutaneous or subcutaneous nodules and 56 (28.87%) palpable lymph nodes were studied. 87 (44.85%) true positive, 92 (47.42%) true negative, 3 (1.55%) false positive and 12 (6.19%) false negative cytology results were found. High sensitivity (87.89%), specificity (96.84%) and diagnostic accuracy (93.72%) were confirmed.

DISCUSSION

The quality assurance of fine needle aspiration biopsy in these patients with recurrent and metastatic melanoma meets the international requirements.

Prognostic importance of the extent of ulceration in patients with clinically localized cutaneous melanoma

OBJECTIVE

To determine the prognostic value of the extent of ulceration, categorized as diameter of ulceration and as percentage of invasive melanoma diameter.

BACKGROUND

Ulceration is an adverse prognostic factor for clinically localized primary cutaneous melanoma. However, the prognostic significance of the extent of ulceration remains unclear.

METHODS

Clinicopathologic and follow-up data on 4661 patients treated at a single center were analyzed.

RESULTS

Both the presence and extent of ulceration were independent predictors of survival. The 5-year melanoma-specific survival (MSS) for ulcerated and nonulcerated melanomas was 77.6% and 91.3%, respectively. The 5-year MSS for minimally/moderately ulcerated melanomas (≤70% or ≤5 mm) was 80.4% and 82.7%, respectively, compared to extensively ulcerated melanomas (>70% or >5 mm), which had a 5-year MSS of 66.4% and 59.3%. On multivariate analysis, tumor thickness and the presence/absence of mitoses were the most powerful predictors of MSS. The presence of ulceration was also an independent predictor of poorer MSS (hazard ratio [HR] = 1.55, P < 0.001). Patients with minimally/moderately ulcerated tumors (≤70% or ≤5 mm) had a significantly higher risk of death (HR = 1.53 and HR = 1.39, respectively) compared to nonulcerated melanoma, as did patients with extensively ulcerated tumors (>70%: HR = 2.20 and >5 mm: HR = 2.03).

CONCLUSIONS

Extent of ulceration (measured either as diameter or percentage of tumor width) provides more accurate prognostic information than the mere presence of ulceration. This has potential implications for melanoma patients with regard to prognosis, staging, management, and eligibility for clinical trials. We recommend that extent of ulceration be recorded in pathology reports for all ulcerated primary cutaneous melanomas.

Surgical treatment of malignant melanoma: practical guidelines

Melanoma is currently the fifth and sixth most common solid malignancy diagnosed in men and women, respectively. Although accounting for only 4% of cases of all cutaneous malignancies, melanoma accounts for more than 75% of all deaths from skin cancer. This article discusses epidemiology and risk factors, proper biopsy technique, advanced histologic evaluation of biopsy material, assessment of tumor thickness and staging, preoperative metastatic evaluation, excision margin, treatment of regional lymph nodes, treatment of recurrence, and some special clinical situations.

Multivariate analysis of prognostic factors among 2,313 patients with stage III melanoma: comparison of nodal micrometastases versus macrometastases

PURPOSE

To determine the survival rates and independent predictors of survival using a contemporary international cohort of patients with stage III melanoma.

PATIENTS AND METHODS

Complete clinicopathologic and follow-up data were available for 2,313 patients with stage III disease in an updated and expanded American Joint Committee on Cancer (AJCC) melanoma staging database. Kaplan-Meier and Cox multivariate survival analyses were performed.

RESULTS

Among all 2,313 patients with stage III disease, 81% had micrometastases, and 19% had clinically detectable macrometastases. The 5-year overall survival was 63%; it was 67% for patients with nodal micrometastases, and it was 43% for those with nodal macrometastases (P < .001). Tremendous heterogeneity in survival was observed, particularly in the microscopically detected nodal metastasis subset (from 23% to 87% for 5-year survival). Multivariate analysis demonstrated that in patients with nodal micrometastases, number of tumor-containing lymph nodes, primary tumor thickness, patient age, ulceration, and anatomic site of the primary independently predicted survival (all P < .01). When added to the model, primary tumor mitotic rate was the second-most powerful predictor of survival after the number of tumor-containing nodes. In contrast, for patients with nodal macrometastases, the number of tumor-containing nodes, primary ulceration, and patient age independently predicted survival (P < .01).

CONCLUSION

In this multi-institutional analysis, we demonstrated remarkable heterogeneity of prognosis among patients with stage III melanoma, especially among those with nodal micrometastases. These results should be incorporated into the design and interpretation of future clinical trials involving patients with stage III melanoma.

Constitutive expression of the alpha4 integrin correlates with tumorigenicity and lymph node metastasis of the B16 murine melanoma

The lymphatic system plays a critical role in melanoma metastasis, and yet, virtually no information exists regarding the cellular and molecular mechanisms that take place between melanoma cells and the lymphatic vasculature. Here, we generated B16-F1 melanoma cells that expressed high (B16alpha(4)+) and negligible (B16alpha(4)-) levels of alpha(4) integrin to determine how the expression of alpha(4) integrins affects tumor cell interactions with lymphatic endothelial cells in vitro and how it impacts lymphatic metastasis in vivo. We found a direct correlation between alpha(4) integrin expression on B16-F1 melanoma cells and their ability to form adhesive interactions with monolayers of lymphatic endothelial cells. Adhesion of B16-F1 melanoma cells to lymphatic endothelial cells was mediated by the melanoma cell alpha(4) integrin binding to its counterreceptor, vascular cell adhesion molecule 1 (VCAM-1), that was constitutively expressed on the lymphatic endothelial cells. VCAM-1 was also expressed on the tumor-associated lymphatic vessels of B16-F1 and B16alpha(4)+ tumors growing in the subcutaneous space of C57BL/6J mice. B16-F1 tumors metastasized to lymph nodes in 30% of mice, whereas B16alpha(4)+ tumors generated lymph node metastases in 80% of mice. B16-F1 melanoma cells that were deficient in alpha(4) integrins (B16alpha(4)-) were nontumorigenic. Collectively, these data show that the alpha(4) integrin expressed by melanoma cells contributes to tumorigenesis and may also facilitate metastasis to regional lymph nodes by promoting stable adhesion of melanoma cells to the lymphatic vasculature.

Fine-needle aspiration biopsy with ultrasound guidance in patients with malignant melanoma and palpable lymph nodes

BACKGROUND

Recurrence after treatment of stage I-II melanoma involves regional lymph nodes in about 50% of patients. A reliable method is needed to evaluate lymph node status (metastatic or not) in the case of palpable lymph nodes.

OBJECTIVES

To evaluate the efficiency of fine-needle aspiration biopsy (FNAB) in examining clinically detected suspicious lymph node in patients followed up after surgical removal of stage I-II melanoma.

PATIENTS AND METHODS

One hundred and twenty FNABs were performed in 67 patients with a suspicious node in an open study conducted in a French melanoma regional referral centre, Hôpital de l'Hôtel-Dieu. Cytodiagnosis was classified as positive, negative, inadequate or inconclusive. Sensitivity, specificity, positive and negative predictive values and positive and negative likelihood ratios were calculated after final histopathological evaluation.

RESULTS

Fifty-eight of 120 FNABs were positive (48%), 50 of 120 (42%) were negative, four of 120 (3%) were inconclusive and eight of 120 (7%) were inadequate. Among the 108 FNABs in which a definitive diagnosis could be given, sensitivity was 98.2% [95% confidence interval (CI) 90.7-99.9] and specificity was 96.1% (95% CI 86.8-98.9).

CONCLUSIONS

FNAB under ultrasound guidance is an efficient tool to discriminate better between cases in which surgical treatment of the lymph node basin should be performed and patients who should return for follow-up. Surgical treatment appears to be required in cases of positive FNAB or in inconclusive cases.

Cutaneous melanoma: estimating survival and recurrence risk based on histopathologic features

The prognosis of melanoma is best understood in terms of a model of tumor progression, in which most melanomas may evolve through two major phases of progression: from a lesion that is nontumorigenic and has little or no capacity for metastasis; to a more advanced lesion that is tumorigenic and may have capacity for metastasis. The likelihood of metastasis varies with a number of attributes of the primary melanoma, including the phase of progression, the Breslow tumor thickness, mitotic rate, and host response to the tumorigenic compartment of the lesion, Clark's level of invasion, and other factors. When distant metastasis has occurred, the prognosis for the patient is very poor. In this monograph, the focus will be the discussion of factors related to the prognosis of melanomas that at diagnosis are clinically localized to the primary site.

Presence and maturity of dendritic cells in melanoma lymph node metastases

Immune avoidance mechanisms play a key role in the successful dissemination of melanoma. One mechanism whereby this could be achieved is by interfering with dendritic cell (DC) presentation of tumour-associated antigens to naïve T cells. In particular, immature DCs characterized by the absence of accessory molecules are known to be immunosuppressive and to be involved in the induction of tolerance. The present study has investigated the presence and activation status of DCs within melanoma metastases in the regional lymph nodes. Using image analysis techniques, the expression of Factor XIIIa (FXIIIa), CD40, CD83 and HLA-DR and the morphological features of DCs were examined in paraffin sections from 26 lymph nodes containing melanoma metastases. DCs expressing FXIIIa were found in 70% of the lymph nodes. The number of DCs identified was generally small but there were more concentrated areas of DCs designated as hotspots. In these areas of high FXIIIa staining, the percentage area occupied by DCs varied between 0.1% and 10%. The majority of FXIIIa-positive cells did not express the DC maturation markers CD83 or CD40 and morphologically were rounded with few dendrites, indicating that they were immature. The cells did, however, express high levels of HLA-DR, suggesting that they have the ability to present antigen but lack the accessory molecules required to initiate an immune response. Immature DCs, characterized by phenotypic and morphological features, are therefore present within the tumour deposits in lymph nodes infiltrated by melanoma and may specifically modulate the anti-melanoma immune response.

Radiation therapy following lymph node dissection in melanoma patients: treatment, outcome and complications

Adjuvant radiation treatment following lymph node dissection in the melanoma patient has been suggested and investigated in an attempt to gain regional control and improve survival. In this review we discussed the treatment, the loco-regional control, disease-free and survival rates and complications. Historically melanoma has been thought of as a relatively radioresistant tumour. Nowadays, radiation delivered according to the hypofractionated schedule is the most used, although there are no data to confirm that this schedule improves the therapeutic impact. Almost all the reviewed studies were retrospective, which could have led to an underestimation of the true incidence of the treatment toxicity and morbidity. Adjuvant radiotherapy after lymph node dissection for metastases of melanoma seems to improve loco-regional control without improving overall survival. The available data indicate the need for improved regional control rates in patients with extranodal extension, multiple involved nodes (more than three) and patients with large involved nodes (larger than 3 cm). The complications seem manageable and consist mainly of fibrosis and edema.

Candidate???s Thesis: The Application of Sentinel Node Radiolocalization to Solid Tumors of the Head and Neck: A 10-Year Experience

OBJECTIVES/HYPOTHESIS

The goals of the research study were to develop an easily mastered, accurate, minimally invasive technique of sentinel node radiolocalization with biopsy (SNRLB) in the feline model; to compare it with blue-dye mapping techniques; and to test the applicability of sentinel node radiolocalization biopsy in three head and neck tumor types: N0 malignant melanoma, N0 Merkel cell carcinoma, and N0 squamous cell carcinoma.

STUDY DESIGN

Prospective consecutive series studies were performed in the feline model and in three head and neck tumor types: N0 malignant melanoma (43 patients), N0 Merkel cell carcinoma (8 patients), and N0 squamous cell carcinoma (20 patients).

METHODS

The technique of sentinel node radiolocalization with biopsy was analyzed in eight felines and compared with blue-dye mapping. Patterns of sentinel node gamma emissions were recorded. Localization success rates were determined for blue dye and sentinel node with radiolocalization biopsy. In the human studies, all patients had sentinel node radiolocalization biopsy performed in a similar manner. On the morning of surgery, each patient had sentinel node radiolocalization biopsy of the sentinel lymph node performed using an intradermal or peritumoral injection of technetium Tc 99m sulfur colloid. Sentinel nodes were localized on the skin surface using a handheld gamma detector. Gamma count measurements were obtained for the following: 1) the "hot" spot/node in vivo before incision, 2) the hot spot/node in vivo during dissection, 3) the hot spot/node ex vivo, 4) the lymphatic bed after hot spot/node removal, and 5) the background in the operating room. The first draining lymph node(s) was identified, and biopsy of the node was performed. The radioactive sentinel lymph node(s) was submitted separately for routine histopathological evaluation. Preoperative lymphoscintigrams were performed in patients with melanoma and patients with Merkel cell carcinoma. In patients with head and neck squamous cell carcinoma, the relationship between the sentinel node and the remaining lymphatic basin was studied and all patients received complete neck dissections. The accuracy of sentinel node radiolocalization with biopsy, the micrometastatic rate, the false-negative rate, and long-term recurrence rates were reported for each of the head and neck tumor types. In the melanoma study, the success of sentinel node localization was compared for sentinel node radiolocalization biopsy, blue-dye mapping, and lymphoscintigraphy. In the Merkel cell carcinoma study, localization rates were evaluated for sentinel node radiolocalization biopsy and lymphoscintigraphy. In the head and neck squamous cell carcinoma study, the localization rate of sentinel node radiolocalization biopsy and the predictive value of the sentinel node relative to the remaining lymphatic bed were determined. All results were analyzed statistically.

RESULTS

Across the different head and neck tumor types studied, sentinel node radiolocalization biopsy had a success rate approaching 95%. Sentinel node radiolocalization biopsy was more successful than blue-dye mapping or lymphoscintigraphy at identifying the sentinel node, although all three techniques were complementary. There was no instance of a sentinel node-negative patient developing regional lymphatic recurrence. In the head and neck squamous cell carcinoma study, there was no instance in which the sentinel node was negative and the remaining lymphadenectomy specimen was positive.

CONCLUSION

In head and neck tumors that spread via the lymphatics, it appears that sentinel node radiolocalization biopsy can be performed with a high success rate. This technique has a low false-negative rate and can be performed through a small incision. In head and neck squamous cell carcinoma, the histological appearance of the sentinel node does appear to reflect the regional nodal status of the patient.

The amount of metastatic melanoma in a sentinel lymph node: does it have prognostic significance?

BACKGROUND

The amount of metastatic disease in the sentinel lymph node (SLN) is examined as a prognostic factor in malignant melanoma.

METHODS

SLN mapping was performed on 592 patients with stage I and II malignant melanoma from March 1, 1994, through December 31, 1999. One hundred four patients were found to have 134 sentinel SLNs containing metastatic melanoma. The slides were reviewed, and the size of the metastatic melanoma in each SLN was measured. The size of the metastatic deposit was defined as macrometastasis (>2 mm), micrometastasis (< or =2 mm), a cluster of cells (10-30 grouped cells) in the subcapsular space or interfollicular zone, or isolated melanoma cells (1 to > or =20 individual cells) in subcapsular sinuses.

RESULTS

The number of metastases in each SLN was isolated melanoma cells, n = 5 (3.7%); cluster of cells, n = 35 (26.1%); < or =2 mm, n = 45 (33.6%); and >2 mm, n = 49 (36.7%). Seventy-nine patients (76%) had a single positive SLN. The size of the largest nodal metastasis was used to stratify patients with multiple positive SLNs. The overall 3-year survival for patients with SLN micrometastases was 90%, versus 58% for patients with SLN macrometastases (P =.004).

CONCLUSIONS

The amount of metastatic melanoma in an SLN is an independent predictor of survival. Patients with SLN metastatic deposits >2 mm in diameter have significantly decreased survival.

The role of molecular staging in malignant melanoma

AIMS

To review the role of tyrosinase RT-PCR in the detection of clinically occult metastatic disease, both within the regional lymph nodes and peripheral blood of patients with malignant melanoma. Secondly, to assess whether the detection of such minimal disease has clinical implications for patients with melanoma.

METHODS

A review of the literature was undertaken by searching the MEDLINE database for the period 1966-2002 without any language restrictions. Keywords included 'Molecular staging of melanoma', 'Reverse transcription polymerase chain reaction', 'Malignant melanoma' and 'Tyrosinase'.

CONCLUSIONS

Detection of tyrosinase RT-PCR positive cells within the peripheral blood correlates with the clinical stage of malignant melanoma, the primary tumour thickness and other known prognostic indicators. Positive tyrosinase RT-PCR is associated with a reduction of disease-free survival and overall survival. Current studies demonstrate a higher rate of recurrence in RT-PCR positive patients with clinical stage II and III disease. Implications of a positive result within the regional lymph nodes are less well defined. A significant correlation has been demonstrated between positive results and increasing primary melanoma thickness. However, a large number of false-positive results have been demonstrated, due to benign naevi and schwann cells, which may hamper any statistically significant conclusions being reached.

[Marking the route of lymphatic spread of melanoma and sentinel lymph node biopsy]

<zakljucak> Biopsija limfnih zlezda strazara je postupak koji, uz relativno nizak morbiditet, daje precizne podatke o stanju regionalnog limfonodalnog basena bolesnika sa melanomom koze. Stanje regionalnih limfnih zlezda je kljucni prognosticki parametar, veoma bitan za planiranje daljeg lecenja. Za uspesnu identifikaciju i histopatolosku obradu SLN neophodna je saradnja hirurga, nuklearnog radiologa i histopatologa. Dijagnostikovanjem okultnih metastaza u regionalnim limfnim zlezdama identifikuju se bolesnici kojima treba uciniti kompletnu limfonododisekciju, kao i oni koji mogu imati koristi od primene adjuvantne antitumorske terapije. Uvodjenjem ovog postupka dilema izvodjenja ili ne ELND vise ne postoji. Tehnicki i kadrovski zahtevi medjutim, jos uvek je ne svrstavaju u rutinske standardne postupke u lecenju melanoma. Pronalazenje mikrometastaza u regionalnim limfnim zlezdama menja stadijum bolesti u kome je bolesnik do tada bio (migracija stadijuma, Will Rogers fenomen). Novim klasifikacionim sistemom definise se klinicki i patoloski stadijum bolesti (14, 114). Ukoliko su regionalni limfonodusi ispitivani klinickim i/ili radioloskim postupcima, moze se govoriti o klinickom stadijumu bolesti. Za odredjivanje patoloskog stadijuma neophodna je histoloska evaluacija limfnih zlezda dobijenih bilo selektivnom bilo elektivnom limfadenektomijom. SLNB se smatra jednim od najvecih napredaka u terapiji melanoma u zadnjoj deceniji XX veka (4, 111). Ocekuje se da ce postati standard u lecenju bolesnika sa klinicki negativnim limfnim zlezdama (99, 111, 112), posebno sa usvajanjem novog sistema za odredjivanje stadijuma koze (14, 114, 115).

Selective sentinel lymphadenectomy for malignant melanoma

To date, selective sentinel lymphadenectomy (SSL) should be considered a standard approach for staging patients with primary invasive melanoma greater than or equal to 1 mm. It is imperative that the multidisciplinary team master the techniques of preoperative lymphoscintigraphy, intraoperative lymphatic mapping, and postoperative pathologic evaluation of the sentinel lymph nodes (SLNs). A SLN is defined as a blue, "hot", or any subsequent lymph node greater than 10% of the in vivo count of the hottest lymph node and as an enlarged or indurated lymph node. Frozen sections are not recommended. For extremity melanoma, delayed SSL may be performed. Preoperative lymphoscintigraphy for extremity melanoma may be done the night before so that surgery can be scheduled as the first case of the following day. Every surgeon who uses blue dye should be cognizant of the potential adverse reaction to isosulfan blue and treatment for such a potential fatal reaction. A complete lymph node dissection is done if the SLN is found to be positive. Elective lymph node dissection should not be done if SSL can be done as a staging procedure. It is important for investigators involved with SSL to follow the clinical outcome of their patients so that the role of SSL can be further defined.

Pattern and incidence of first site recurrences following sentinel node procedure in melanoma patients

Studies of large series of melanoma patients indicated that the average incidence of developing a recurrence during follow-up was 40%. The most frequent first sites of these recurrences were the regional lymph nodes. We hypothesized that the sentinel node (SN) procedure may change the pattern of recurrence by reducing the number of first recurrences in the regional lymph node basin during follow-up to a negligible number, and that locoregional cutaneous and distance metastases are the major future sites of recurrence. We further studied the influence of SN status together with different influential factors on prognosis. An SN procedure with a triple technique was performed in 250 consecutive patients with proven AJCC stages I and II cutaneous melanoma. The median follow-up was 38 months. So far, 44 patients (18%) have developed a recurrence of the disease. The distribution of localization of the first metastases was as follows: 23 patients (52%) with a locoregional cutaneous recurrence; 4 (9%) with recurrence in the regional lymph node basin; 2 (5%) with recurrence in an interval node; and 15 (34%) with distant recurrence. The relative risk of developing recurrence for SN-positive patients is 4.2; for Breslow thickness of 1.51 to 4.00 mm it is 5.5, and thicker than 4.0 mm it is 6.2; for lymphatic invasion 7.6; and for ulceration 3.8. We conclude that the SN procedure changes the pattern of recurrences during follow-up by reducing the number of first recurrences within the regional lymph node basin to a negligible number. High Breslow thickness, lymphatic invasion, and ulceration of the primary melanoma are strong risk factors for recurrence.

Surgical approaches to malignant melanoma. Practical guidelines

Practical guidelines for the surgical approach to malignant melanoma are discussed in detail. Topics include diagnosis and proper biopsy technique; the appropriate preoperative metastatic workup; width of excision margins; treatment of the regional lymph nodes including cutaneous lymphoscintigraphy, intraoperative lymphatic mapping, and sentinel lymphadenectomy; postoperative follow-up schedules; management of local recurrence including surgical resection, isolated limb perfusion, intralesional therapy, adjuvant immunotherapy; management of special clinical situations including subungal melanoma, plantar melanoma, melanoma on the face, melanoma in pregnancy, and the treatment of lesions of uncertain diagnosis.

Common prognostic factors for stage III melanoma patients and for stage I and II melanoma patients with recurrence to their regional lymph nodes

This study was undertaken in order to identify the prognostic factors for stage III malignant melanoma patients. In addition we compared the survival data of these patients with data from patients presenting with stage I and II disease who subsequently developed a regional nodal recurrence, in order to identify common prognostic factors and to compare the biological behaviour of the two groups. We retrospectively examined two groups of patients. The first consisted of 116 patients with stage III malignant melanoma and the second consisted of 57 patients with stage I and II malignant melanoma that were found to have regional lymph node metastases diagnosed at least 6 months after surgical treatment of their primary lesion. The age of the patients, the number of disease-involved lymph nodes, the site of the primary lesion and the presence or not of palpable lymph nodes proved to be significant prognostic factors of the first group. We also analysed the survival data of the second group and compared it with data from the stage III patients. The 5 year survival starting from the time after diagnosis of the primary lesion was 47.37% compared with 25.86% in stage III patients; however, this difference was not statistically significant. Patients who present with stage III malignant melanoma seem to have a more aggressive phenotype than stage I and II malignant melanoma patients who present with recurrent disease in their regional lymph nodes. Disease behaviour is dictated by the number of disease-involved lymph nodes, the site of the primary lesion and the type of surgical procedure performed (elective or therapeutic lymph node dissection).

Improved staging of node-negative patients with intermediate to thick melanomas (>1 mm) with the use of lymphatic mapping and sentinel lymph node biopsy

BACKGROUND

Elective lymph node dissection (ELND) may contribute to a survival benefit in certain stratified subsets of melanoma patients. We hypothesized that lymphatic mapping and sentinel lymph node (SLN) biopsy (with complete node dissection if metastases are present) may improve both staging and survival of patients with clinically negative nodes, without subjecting all patients to the morbidity associated with complete ELND.

METHODS

We reviewed the data for all 14,914 N0 patients of the AJCC Melanoma Staging Database to determine the effect of SLN biopsy and ELND on staging and survival.

RESULTS

Retrospective analysis revealed that there was an apparent statistically significant survival advantage to SLN biopsy in patients with melanomas > 1 mm (n = 9024; 68.5% and 26.2% reduction in mortality compared with patients staged to be N0 by clinical exam and ELND, respectively; P < .0001). Five-year survivals were 90.5%, 77.7%, and 69.8%, respectfully, for patients staged by SLN biopsy (n = 2552), ELND (n = 2014), and clinical examination alone (n = 5192). The survival advantage of SLN biopsy was statistically significant for each T-stage category (T2, T3, and T4) and ulceration status. There was no advantage to SLN biopsy in patients with melanomas <1 mm (n = 5890).

CONCLUSIONS

SLN biopsy provides more accurate staging and may contribute to a survival benefit in populations of patients with melanoma.

Management of high-risk melanoma

Improved treatment options for patients with high-risk melanoma are of great importance for clinicians who participate in the care of these patients. There remains an overall lack of response to existing treatment options, which continues to fuel the efforts of basic scientists and clinicians to pursue other approaches for the treatment of melanoma that is no longer limited to the skin. Continued investigation into the innovative and concurrent use of surgery, chemotherapy, immunotherapy, and radiation therapy holds significant promise for improved outcomes in the management of patients with this devastating disease.

Should adjuvant radiotherapy be recommended following resection of regional lymph node metastases of malignant melanomas?

BACKGROUND

Several authors have recommended adjuvant radiotherapy following resection of regional lymph node metastases in cutaneous malignant melanoma. There is, however, little evidence from controlled trials that patients benefit from this treatment.

OBJECTIVES

To evaluate the usefulness of adjuvant radiotherapy following resection of lymph node metastases in cutaneous malignant melanoma.

METHODS

We performed a retrospective study comparing 58 patients who underwent radiotherapy following resection of regional lymph node metastases with 58 controls from another centre who exclusively underwent regional lymphadenectomy. Patients and their controls were matched with respect to the number of tumour-bearing lymph nodes (1 vs. > 1) and to gender, although the proportion of thick tumours was greater in the irradiation group.

RESULTS

The overall survival curves were almost identical in the two groups. There were nine disease recurrences in the study group and 12 in the control group (not significant). Regional recurrences in the irradiated patients were usually accompanied by metastases at other sites.

CONCLUSIONS

The present study does not support the recommendation of adjuvant radiotherapy following resection of regional lymph node metastases in patients with malignant melanoma.

The role of sentinel lymph nodes in malignant melanoma

Selective sentinel lymph node dissection should be considered a standard approach in the treatment of primary malignant melanoma. With the combination of blue dye and radioisotope mapping, the sentinel lymph nodes (SLNs) can be harvested with pinpoint accuracy. This article compares blue dye and radioisotope mapping techniques. Based on the clinical outcome data of selective sentinel lymph node dissection, micrometastasis to the SLNs carries a poor prognosis for patients with primary invasive melanoma.

Melanoma metastases through the lymphatic system

Pathologists can expect to receive sentinel nodes from patients with cancers other than melanoma, such as breast, vulvar, thyroid, and colon cancers. Many of the recommendations in this article can be extrapolated to cancers other than melanoma, but there are some peculiarities that relate to each type of tumor. The pathologist should carefully review the published literature before attempting to evaluate sentinel nodes from patients with an unfamiliar form of cancer.

Prognostic factors of overall survival in patients with delayed lymph node dissection for cutaneous malignant melanoma

To date, no study of melanoma patients who have undergone delayed lymph node dissection (DLND) has focused on the independent prognostic factors of overall survival, as calculated from surgery on the primary. Using Kaplan-Meier estimates and Cox's proportional hazard model, the significance of prognostic factors was evaluated in 173 patients who developed clinically apparent regional lymph node metastases. When calculated from excision of the primary tumour (median Breslow thickness 3.0 mm), the median survival was 38 months. When calculated from DLND, the median survival was 19 months. Multifactorial analysis revealed that the number of nodes involved at the time of DLND significantly affected both survival calculated from primary tumour excision (P = 0.0002) and survival calculated from DLND (P < 0.0001). In contrast, the well-known risk factors of primary melanoma did not significantly influence overall survival or survival after DLND. However, the remission duration between surgery on the primary and DLND clearly depended on epidermal ulceration (P = 0.001), Breslow thickness (P = 0.009) and the site of the primary melanoma (P = 0.048). Thus, in patients submitted to DLND, the risk factors of primary melanoma influence the early period of the disease, until metastatic lymph nodes become palpable. With regard to overall survival, only the extent of nodal disease determines the prognosis of these patients.

Predicting sentinel and residual lymph node basin disease after sentinel lymph node biopsy for melanoma

BACKGROUND

The selection of patients for sentinel lymph node biopsy (SNB) and selective lymphadenectomy for histologically positive sentinel lymph nodes (SLND) are areas of debate. The authors of the current study attempted to identify predictors of metastases to the sentinel and residual nonsentinel lymph nodes in patients with melanoma.

METHODS

The Indiana University Interdisciplinary Melanoma Program computerized database was queried to identify all patients who underwent SNB for clinically localized cutaneous melanoma. Demographic, surgical, and histopathologic data were recorded. Univariate and multivariate logistic regression analyses were performed to identify associations with SNB and nonsentinel lymph node positivity. Classification tree and logistic procedures were performed to identify the ideal tumor thickness cutpoint at which to perform SNB.

RESULTS

Two hundred seventy-five SNB procedures were performed to stage 348 regional lymph node basins for occult metastases from melanoma. Of the 275 melanomas, 54 (19.6%) had a positive SNB, as did 58 of 348 basins (16.7%). Classification and logistic regression analysis identified a Breslow depth of 1.25 mm to be the most significant cutpoint for SNB positivity (odds ratio 8. 8:1; P = 0.0001). By multivariate analyses, a Breslow thickness cutpoint >/= 1.25 mm (P = 0.0002), ulceration (P = 0.005), and high mitotic index (> 5 mitoses/high-power field; P = 0.04) were significant predictors of SNB results. SLND was performed in 53 SNB positive patients, 15 of whom (28.3%) had at least 1 additional positive lymph node. SLND positivity was noted across a wide range of primary tumor characteristics and was associated significantly with multiple positive SN, but not with any other variable. SNB result correlated significantly with disease free and overall survival.

CONCLUSIONS

Patients with a Breslow tumor thickness >/= 1. 25 mm, ulceration, and high mitotic index are most likely to have positive SNB results. SLND is recommended for all patients after positive SNB because it is difficult to identify patients with residual lymph node disease.

Judging the therapeutic value of lymph node dissections for melanoma

BACKGROUND

The management of the regional lymph nodes remains controversial for early-stage melanoma and for those patients with lymph node metastases; American Joint Committee on Cancer stage III. This study examines the importance of quality of the surgical resection measured by the extent of lymph node dissection (quartile of the total number of lymph nodes removed) to determine if this factor is an important prognostic factor for survival.

STUDY DESIGN

We reviewed our computer-assisted database of more than 8,700 melanoma patients prospectively collected from 1971 through the present to identify patients who underwent lymph node dissection for stage III melanoma. We included only patients who had their nodal dissections performed at our institute. Patients who underwent sentinel lymph node dissection were excluded. These patients were then analyzed as a group and by individual lymphatic basins: cervical, axillary, and inguinal basins. Univariate and multivariate analyses were used to examine the model that included tumor burden, thickness of the primary melanoma, gender, age, clinical status of the lymph nodes (palpable versus not palpable), and the primary site. The survival and recurrence rates were analyzed using the Cox proportional hazards model.

RESULTS

Five hundred forty-eight patients underwent regional lymph node dissections. Of these patients, 214 underwent axillary dissections, 181 inguinal dissections, and 153 cervical dissections. The extent of the nodal dissections was based on the quartile of nodes excised, ranging from 1 to 98 (mean +/- SD = 25.8 +/- 15.8). Patients were stratified by tumor burden and quartile of number of lymph nodes removed. The overall 5-year survival of patients with four or more lymph nodes having tumor and the highest quartile of lymph nodes removed was 44% and was 23% for the lowest quartile of total lymph nodes excised (p = 0.05). By univariate analysis, tumor burden (p = 0.0001), quartile of total lymph nodes removed (p = 0.043), and primary site (p = 0.047) were statistically significant for predicting overall survival. Gender, clinical status of the nodes, primary tumor thickness, age, and dissected basin were not significant (p > 0.05). By multivariate analysis only the tumor burden (p = 0.0001) and quartile of lymph nodes resected (p = 0.044) were statistically significant.

CONCLUSIONS

The extent of lymph node dissection for melanoma when analyzed by quartiles is an independent factor in overall survival. This factor appears to be more important with increasing tumor burden in the lymphatic basin. The extent of lymph node dissection should be considered as a prognostic factor in the design of clinical trials that involve stage III melanoma.

Aspiration biopsy and the clinical management of patients with malignant melanoma and palpable regional lymph nodes

BACKGROUND

The presence of lymph node metastases in patients with malignant melanoma implies a significant decrease in survival. The authors investigated the efficacy of fine-needle aspiration biopsy (FNAB) in the diagnosis of metastatic malignant melanoma in 115 patients with melanoma and clinically suspicious regional lymph nodes.

METHODS

One hundred thirty-three FNABs were performed by cytopathologists after referral from surgeons or oncologists using a 25-gauge or 27-gauge needle.

RESULTS

The cytologic diagnosis was negative in 35, atypical in 1, suspicious in 2, and positive for malignant melanoma in 95. Regional lymph node dissections were performed in 78 patients. Of these, 70 positive FNABs were confirmed with no false-positive results. The atypical FNAB was proven positive for malignant melanoma at surgery. Of the two suspicious FNABs, one was confirmed as positive and one showed dermatopathic lymphadenopathy. Of the 35 negative FNAB specimens, 5 patients underwent surgery; 3 FNABs were found to be negative and 2 FNABS were falsely negative. Twenty patients with negative aspirates were followed clinically for 22-45 months (mean, 32 months); 19 patients had no evidence of disease and 1 patient died of disseminated melanoma.

CONCLUSIONS

FNAB of palpable lymphadenopathy in patients with malignant melanoma can provide a rapid and accurate assessment of lymph node status and expedite the therapeutic management of these patients.

Current therapy of cutaneous melanoma

Melanoma is a growing public health problem. Optimal care of the melanoma patient is multidisciplinary, but plastic surgeons and other surgical specialties play a central role in the management of these patients. Although surgery remains the mainstay of therapy for melanoma, several recent clinical studies have helped to clarify the biology of the disease and have changed the patterns of care for patients with melanoma. The advent of lymphatic mapping for interrogation of regional lymph nodes and interferon as the first effective postsurgical adjuvant therapy have had a major impact on the care of melanoma in the United States and elsewhere. This article will review the current clinical approach and therapy for cutaneous melanoma. The diagnosis, prognostic variables, staging evaluation, current surgical and medical treatment, and follow-up guidelines for patients with all stages of melanoma are reviewed. Recent studies, controversies, and directions of future investigational therapies will be discussed.

Melanoma. A multidisciplinary approach for the general surgeon

Advances in the understanding of the biology and treatment of melanoma have moved the care of melanoma patients into an increasingly multidisciplinary environment. Surgeons must understand these advances because they will often be responsible for directing the overall care of these patients. Most patients with melanomas more than 1 mm in diameter and no evidence of metastatic disease should be offered SLNB to more accurately stage them and direct decisions about participation in postoperative adjuvant therapy trials. Until the results of the MSLT are known, the effect of SLNB and ELND on outcome remains unknown. SLNs should be analyzed with serial sectioning and immunohistochemistry to avoid missing micro-metastatic disease. Based on the results of the ECOG-1684 trial, the FDA approved IFN-alpha 2b for the adjuvant treatment of melanoma patients with thick primary tumors (> 4 mm) or resected nodal disease. IFN-alpha 2b treatment is expensive and potentially toxic. The data from ECOG-1684 do not support the use of IFN-alpha 2b in patients with node-negative disease. In light of the ECOG-1690 trial results, the role of high-dose IFN-alpha 2b in the management of patients with resected nodal disease is considerably less clear. Any recommendations for treatment with high-dose IFN-alpha 2b should be made only after weighing the costs, side effects, and potential benefits for individual patients. Numerous, less toxic, promising, adjuvant immunotherapeutic strategies have been developed and are being tested in multicenter, prospective, randomized trials. These strategies include GMK, PMCV, and Melacine. If the results of any of these trials show a survival advantage compared with placebo or equivalent survival compared with IFN-alpha 2b, these immunotherapeutic agents will become the adjuvant treatment of choice for patients with resected high-risk melanoma. RT-PCR detection of tyrosinase in SLNs can identify patients with submicroscopic nodal disease who may be at increased risk for recurrence or death from melanoma. An ongoing, prospective, randomized trial will determine whether patients with histologically negative but RT-PCR-positive SLNs will benefit from lymphadenectomy or adjuvant IFN-alpha 2b therapy. RT-PCR can also identify minimal residual disease in peripheral blood and bone marrow from patients with high-risk melanoma, but RT-PCR analysis of peripheral blood and bone marrow is still experimental, and procedural details need to be standardized and prospectively validated in large patient groups before its use can be considered the standard of care.

Validation of the accuracy of intraoperative lymphatic mapping and sentinel lymphadenectomy for early-stage melanoma: a multicenter trial. Multicenter Selective Lymphadenectomy Trial Group

OBJECTIVE

To evaluate the multicenter application of intraoperative lymphatic mapping, sentinel lymphadenectomy, and selective complete lymph node dissection (LM/SL/SCLND) for the management of early-stage melanoma.

SUMMARY BACKGROUND DATA

The multidisciplinary technique of LM/SL/SCLND has been widely adopted, but not validated in a multicenter trial. The authors began the international Multicenter Selective Lymphadenectomy Trial (MSLT) 5 years ago to evaluate the survival of patients with early-stage primary melanoma after wide excision alone versus wide excision plus LM/SL/SCLND. This study examined the accuracy of LM/SL/SCLND in the MSLT, using the experience of the organizing center (John Wayne Cancer Institute [JWCI]) as a standard for comparison.

METHODS

Before entering patients into the randomization phase, each center in the MSLT was required to finish a 30-case learning phase with complete nuclear medicine, pathology, and surgical review. Selection of MSLT patients in the LM/SL/SCLND treatment arm was based on complete pathologic and surgical data. The comparison group of JWCI patients was selected using these criteria: primary cutaneous melanoma having a thickness > or =1 mm with a Clark level > or =III, or a thickness <1 mm with a Clark level > or =IV (MSLT criterion); LM/SL performed between June 1, 1985, and December 30, 1998; and patient not entered in the MSLT. The accuracy of LM/SL/SCLND was determined by comparing the rates of sentinel node (SN) identification and the incidence of SN metastases in the MSLT and JWCI groups.

RESULTS

There were 551 patients in the MSLT group and 584 patients in the JWCI group. In both groups, LM performed with blue dye plus a radiocolloid was more successful (99.1 %) than LM performed with blue dye alone (95.2%) (p = 0.014). After a center had completed the 30-case learning phase, the success of SN identification in the MSLT group was independent of the center's case volume or experience in the MSLT.

CONCLUSIONS

Lymphatic mapping and sentinel lymphadenectomy can be successfully learned and applied in a standardized fashion with high accuracy by centers worldwide. Successful SN identification rates of 97% can be achieved, and the incidence of nodal metastases approaches that of the organizing center. A multidisciplinary approach (surgery, nuclear medicine, and pathology) and a learning phase of > or =30 consecutive cases per center are sufficient for mastery of LM/SL in cutaneous melanoma. Lymphatic mapping performed using blue dye plus radiocolloid is superior to LM using blue dye alone.

Lymphatic mapping and sentinel lymphadenectomy after wide local excision of primary melanoma

BACKGROUND

Lymphatic mapping and sentinel lymphadenectomy (LM/SL) are generally avoided in patients who have already undergone wide local excision (WLE) of a primary melanoma, because of concern that disruption of the cutaneous lymphatics might alter lymphatic flow to the sentinel node. We reviewed carefully chosen patients who had undergone LM/SL after WLE to identify circumstances that might make this approach otherwise safe and clinically accurate.

STUDY DESIGN

From our melanoma database of 8,300 patients, of whom 1,015 had undergone LM/SL, we retrospectively identified 47 patients who had previously undergone WLE. Patient and tumor characteristics were collected and compared with followup data from clinic files.

RESULTS

Median WLE surgical margins before LM/SL were 2.0 cm and most patients had extremity lesions. Eleven of the 47 patients (23%) had tumor-involved sentinel nodes, and 8 of these patients (73%) had a solitary nodal metastasis. With a median followup period of 36 months, 3 sentinel node-negative patients developed nodal recurrences. Two of these patients had positive sentinel nodes on pathology re-review and were not considered failures of the lymphatic mapping surgical procedure. The third patient developed in-transit metastases and delayed nodal recurrence. An additional patient, who had a primary tumor on the trunk, developed a nodal recurrence in the basin opposite that identified by lymphoscintigraphy. The overall error rate of the technique was 4 in 36 (11%). This included 2 pathology misdiagnoses (5.6%), 1 nodal recurrence associated with in-transit regional metastases (2.8%), and 1 lymphatic mapping error (2.8%).

CONCLUSIONS

LM/SL can be cautiously performed in patients who have undergone previous WLE if the primary resection margin was no greater than 2.0 cm and the primary was not in a region of ambiguous drainage. Lymphatic mapping may be inaccurate when melanomas have been resected with large margins, especially if the wound was closed with rotation flaps, and when melanomas are on the head and neck or trunk regions.